Basic Information
| Provider Information | |||||||||
| NPI: | 1609078286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ESTRADA | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | DIEGO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8400 NW 33RD ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331221937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059217619 | ||||||||
| FaxNumber: | 3059217355 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 NW 87TH AVE STE 101&102 | ||||||||
| Address2: | |||||||||
| City: | DORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331722654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059217619 | ||||||||
| FaxNumber: | 3059217355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 03/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 045467 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD434575 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME106081 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1021894520003 | 05 | PA | MEDICAID | 1021894520001 | 05 | PA | MEDICAID | 002670300 | 05 | FL | MEDICAID | 3723949000 | 01 | PA | INDEPENDENCE | OTHER | 1021894520002 | 05 | PA | MEDICAID | 30068078 | 01 | PA | KEYSTONE MERCY HEALTH PLAN | OTHER | 2088879 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |